12 - Enteral Nutrition Flashcards
Why do we choose ENTERAL NUTRITION > Parenteral
IMMUNE FUNCTION
BILE + IGA
Mucus Layer / Tight Junction(enterocytes) /MALT = Leukocytes
- *Intestinal Tract Integrity**
- minimize bacterial & endotoxin Translocation*
- *Additional Nutrients are available**
- *Glutamine / MCT / Dietary Fiber**
LESS COSTLY
Contraindications for EN
SEVERE GI Disturances
Intestinal Obstruction
Necrotizing Enterocolitis
Adynamic Ileus
Intractable Vomiting
Upper GI Bleed
Methods of Administration - EN
- *Long Term Access**
- *>4-6 weeks**
Percutaneously Placed Jujustomy = PEJ
most common
Percutaneously Placed Gastotomy = PEG
directly into stomach
Methods of Administration - EN
- *NASOENTERIC TUBES = Short-Term Therapy**
- *<4-6 weeks**
-duodenal
-jejunal
-gastric
NG / OG -gastric
used in patients with INTACT GAG REFLEXES
most common
ND / OD - duodenal
patients with gastroparesis or poor gag-reflexes
NJ / OJ - jujenal
same as -duodenal but also for patients with
PANCREATITIS
Taste Considerations
Protein & Carbs
- *WHOLE PROTEIN** = Taste better
- *more Complex**
- *Simpler Sugars = Fructose / Sucrose / HFCS**
- SWEETER** but *less complex & MORE Osm activity
- opposite from protein*
Protein Sources
Glutamine // L-Arginine
Both good for CRITICALLY ILL PATIENTS
Glutamine
important in maintaining integerity of intestinal mucosa = ENTEROCYTE HELP
Intestinal epithelia consumes glutamine –> IgA
L-Arginine
may improve collagen synthesis & wound healing
ENHANCE T-CELL FUNCTION
Fat Sources
LCT // MCT
Typically a MIX of Both
Long Chain Triglycerides = LCT
Require LIPASE to break down into FFA
more complex
CONTAINS ESSENTIAL FATTY ACIDS
- *Medium Chain Triglycerides = MCT**
- *-Acid**, does not need lipase
- *passively absorbed**
Fat Source
OMEGA 3 FA
for CRITICALLY ILL
Alter CYTOKINE production
- decrease:*
- *TNF & IL-1 Synthesis**
Formula Selection
POLYMERIC FORMULAS
Require:
Normal Digestive & Absorptive Capability
Provide:
100% of RDA for Vit/min/trace elements
Osmolite / Jevity
Formula Selection
MONOMERIC / HYDROLYZED formulas
For ICU patients
since they can’t digest very well
HIGH Osmolarity
since they are BROKEN DOWN
Minimal residue –> more diarrhea
POOR TASTE
Peptide Based
Oligopeptides + di/tripeptides
FAT = 25-30%of calories
NOT COMPLETELY BROKEN DOWN
needs SOME GI FUNCTION
- *Elemental Based**
- *AA / low fat content = 10% FAA**
- *COMPLETELY DIGESTED**
Disease-Specific Formula
CRITICALLY ILL = IMPACT
Arginine Glutamine + OMEGA 3 FA
HIGH PROTEIN = 24%
HIGH BCAA
directly used by skeletal muscle
Disease-Specific Formula
DIABETIC = GLUCERNA
LESS CARBOHYDRATES = 34%
Monosaturated Fats
SOLUBLE & INSOLUBLE FIBER
Disease-Specific Formula
RENAL = NEPRO / RENALCAL
LOW ELECTROLYTES
Concentrated - 1.8 kcal/mL
HIGH Essential AA
more essential –> make non-essential on their own
LESS AZOTEMIA
Disease-Specific Formula
HEPATIC = NUTRIHEP
HIGH BCAA = 45%
to AVOID hepatic Enephalopathy!
Modular Formulas
Single or Multiple nutrients to ENHANCE a standard formula
ALTER THE RATIOS
of principle nutrients, without affecting OTHER nutrients
BENEFIBER
BENEPROTEIN
MCT OIL
BOLUS FEEDINGS
Techniques of Administration
- *HOME SETTING**
- not common in hosptitals*
Gastric Feedings Only
mimics NORMAL feeding
Over 1-4 Hours, MAX 60mL/ min
Start 50-100mL –> increase in 100mL increments
- *Typical amount of formula per feeding is:**
- *240 -400mL**
- depends on caloric density & protein content of formula along with pt’s energy & protein needs*
CONTINUOUS FEEDINGS
Techniques of Administration
HOSPITAL SETTING
Esp: CRITICALLY ILL & DIABETIC PATIENTS
Gastric / Duodenal / Jujenal Feedings
Infused over:
16-24 hours
less aspiration risk vs bolus
CYCLIC INFUSIONS
Techniques of Administration
Supplemental
supplement patient’s oral diets
Also, Gastric / duodenal / jujenal feedings
Infused:
OVERNIGHT = 8-12 hours
Allows patients to be:
MORE MOBILE & does NOT suppress appitite during the day
Continuous Infusion / Cyclic
Techniques of Administration
Start LOW & titrate fairly QUICKLY (q4-8 hours)
CRITICALLY ILL
10-20 mL/hr
increase by 10-20 mL/hr to goal rate
NON-Critically Ill
20-50 mL/hr
increase by 20-25 mL/hr to goal rate
Final goal rate depends on:
caloric density & protein content of the formula
Complications & Monitoring
of EN
- *GASTROINTESTINAL**
- *Intolerance / Diarrhea / Dumping Syndrome**
Aspiration / HYPERglycemia / Fluid Imbalance
Signs that they are NOT TOLERATING the feeding
- *Abdominal Pain** / INCREASED Abdominal GIRTH
- *Vomiting**
- *Tube Feedings in the NG suction**
- monitoring gastric residual no longer recommended*
- *Management of Complications**
- *Gastrointestinal = INTOLERANCE**
HOLD continuous tube feedings for 4-6 hours
RESTART tube feeding @ 50% of previous rate
and titrate back to goal as tolerated
- If above does not work / fails:*
- *Metoclopramide = 10mg po/iv q6hr**
Erythromycin = 250mg po/iv q6hr
- *Advance TUBE –> SMALL BOWEL**
- *ND or NJ tube**
Management of EN Complications
Gastrointestinal = DIARRHEA
Rule out MEDS or C.DIFF
DECREASE RATE BY 50%
Change to –> ISOTONIC or FIBER-Containing
Add –> MODULAR FIBER SUPPLEMENT
benefiber / fibersure
LAST RESORT:
Add Anti-Diarrheal Medication
Loperimide // Diphenoxylate + Atropine
- *Management of EN Complications**
- *Gastrointestinal - DUMPING SYNDROME**
Symptoms:
Weakness / Diaphoresis / Palpitations
Mechanism:
High Osm load in the small intesting
Management - Switch to:
- lower* Osm feeding / decrease tube feeding # or rate
- *CONTINUOUS feeding** vs bolus
- *GASTRIC feeding**
Management of EN Complications
ASPIRATION
Management:
PREVENTION
check tube placement
ELEVATE Head of Bed
30-45 degrees
Post-Pyloric Feedings
Management of EN Complications
HYPERglycemia
OVERFEEDING is most likely cause
Reassess Caloric Needs
- Reduce:*
- *Tube feeding rate** / Carbs
INCREASE:
FAT & more soluble FIBER
- Last resort:*
- *Insulin**, may promote steatosis in overfed patient
Management of EN Complications
Certain Medications
tube feedings should be:
HELD FOR 1 HOUR
BEFORE & AFTER
admin of certain medications
Management of EN Complications
Clogged Feeding Tube
Common
TO PREVENT:
FLUSH 30mL of Lukewarm water Q4hrs
Treat:
>50 mL of lukewarm water
or:
CLOG ZAPPER
combo of enzymes / acids / buffers
